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“Disruptive” doctors are often found to be perfectionists, agency reports

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Dr Evans hits the nail on the head. We have the deep responsibility
of "getting it right" when delivering patient care. When one person in a
team insists on standards which are in the interest of patient care then
this is undoubtedly the correct approach despite the dismay of others who
may feel that this behaviour is inconvenient to them or places additional
demands on their participation. As a paediatric intern I learned from my
consultants that uncompleted input/output charts were totally unacceptable
to the team taking over a shift. On many occasions the person responsible
for this was called back from being off duty to update the charts. After
all how else can you manage the fluid balance of critically ill 2 Kg
infant? Similarly a renowned thoracic surgeon insisted on round the clock
undivided attention of his staff to patients undergoing repair of
congenital cardiac lesions. The outcome - some of the best survival
results ever achieved in the field. Over my 50 year career this pattern
has been repeated in most situations where a physician with a sense of
responsibility has insisted on observing high standards. It seems that the
sin is not the perfectionism that is demanded but most times it is how the
demand is communicated or put into action. In the Feinman report there
appears to be no appreciation of the fact that many of the "emotionally
stable, sociable, highly agreeable, and conscientious," physicians
referred to the group could benefit from redirection of their
communication skills and leadership styles. It is my sincere hope that we
continue to have more than a smattering of perfectionists in our midst but
also that the value that these individuals bring to the plate not be
stifled by some mindless type of brainwashing which usually masquerades
under the guise of a mandatory "training programme" directed at turning
the subject into an obedient servant.

I strongly subscribe to correctness and attention to detail, but also to
considering the feelings of others while trying to put your practices into
action. This requires more team teaching, patience, time and hours of
additional effort often accompanied by the risk that it will not succeed.
I am not surprised that on occasion the conscientious person would become
frustrated. We need more leaders and role models with high standards.

Birds of a feather flock together: is it possible that the agreeable,
conscientious, emotionally stable, perfectionist doctor who is forced out
of his job or finds himself referred to NCAS ... did not fit in with a
bunch of arrogant, disagreeable, disruptive, sociopathic imperfectionists
as workplace colleagues?

This article makes disturbing reading. What precisely is wrong with
being a perfectionist? Surely that is what we all have to be, in Medicine.
We can't get the diagnosis "approximately" right. It has to be right. We
have to be obsessional about removing the right limb or organ - no good
getting it almost right!! Drug dosages must be correct, not almost
correct. We need to know about all the diseases which can afflict our
patients, not just some of them!! And to examine every bit of the person,
not just one bit. Keeping accurate records is essential, not simply
obsessional or perfectionist. To my mind the ideal of perfection is one we
should all aim at all of the time. Not that we will get there, but we must
try. Even if others we work with may seem to have a different approach,
and to care a lot less about attention to detail. This denigrating of
doing your best is all part of the culture of condemning excellence and
high achievement in so many areas of life. Medicine is not about getting
good exam results, it is about going out of your way to care for patients,
and being as conscientious as it is possible to be. Surely that is what
our patients want of us!

Feinmann reports that the Edgecumbe Group assessment of "disruptive
doctors" has shown that rather than being "a queue of arrogant, thoroughly
disagreeable people", they were, for the most part,""emotionally stable,
sociable, highly agreeable, and conscientious" individuals who were
perfectionists. Rather than concentrate on finding some mythical medical
personality trait (as is the vogue in our medical schools at present) the
National Clinical Assessment Service (NCAS) would do better to ask why
emotionally stable people became disagreeable?

Disagreeable behaviour is
usually not viewed in isolation. Oxman et al have helpfully suggested a
quick ABCD of any successful redisorganisation of any service - A minimum
amount of thought has gone into a maximum amount of change, Brownian
motion has been mistaken for progress, Coincidence has been mistaken for
cause and Decibels have been mistaken for leadership. Could this be the
answer that NCAS and this international business psychology consultancy
are looking for? In the present climate, if we take Professor Scotland's
opinions and the Edgecumbe groups research to its full conclusions, some
would suggest that there may be more good clinicians who are emotionally
stable, sociable, highly agreeable, and conscientious appearing before
NCAS.

Feinmann J. "Disruptive" doctors are often found to be
perfectionists, agency reports. BMJ 342:doi:10.1136/bmj.d876

I think that the end product of a doctor is whether he or she has
delivered good care but it good to see that an other end point being
considered is that his or her team has delivered good care. It is easy to
hide behind one's individual competence. Indeed if the outcome of
individual consultations is the only judge of a doctor then clever
individuals will make sure that this work is OK to absolve themselves from
addressing other adverse issues.
We are all part of systems and it is interesting to see some systems nip
any dusruptive behjaviour in the bud (to the great benefit of the
"disruptee") while others just have no mechanisms to do this. Even within
the same system and organisation, some component teams have excellent
governance while others have none. In the latter case, everyone is a
victim.
I think some disruptive individuals seem unwilling to start down the road
of learning and self improvement, which is tragic for them.
This is an important issue in these times of change. Being unable to
manage your own behaviour makes it unlikely that you will be able to
rationally manage change. If that individual is in a key position then
important new systems and governance just do not happen.

Given the amount of managerial pseudo science in the NHS it should
come as no surprise that conscientious doctors get frustrated at times.

That is not to say that unacceptable outbursts should be tolerated,
but I suspect that simply expressing mild disappointment and frustration
with poor management decisions is enough to be labelled a trouble maker.

With more than 1000 referrals in the past year the service reports
that the doctors who were most likely to be referred were older
clinicians, particularly male consultants and singlehanded GPs. But the
vast majority of the 279 clinicians who have undertaken a behavioural
assessment as part of NCAS performance assessment were 'emotionally
stable, sociable, highly agreeable, and conscientious," said Jenny King, a
behavioural assessor for the NCAS service, a chartered psychologist and
partner in the international business psychology consultancy the Edgecumbe
Group.

The key ambiguity in the article "Disruptive doctors" apparently lies
in the usage and origins of the word 'disruptive'. The article states that
the majority of doctors referred were in fact "clinically excellent,
highly agreeable and conscientious perfectionists" - amongst other equally
complementary attributes, that to even the casual reader, appear as polar
opposite adjectives to "disruptive, arrogant prats."

From where and why does this chasm of opinion difference originate?
What qualifies a doctor as disruptive? A clinician frustrated at the lack
of support, facilities and like minded, avant-garde individuals available
for instigating a shared vision of improved patient care? We live in a non
-complaining society that encourages conformation yet discourages
individual thought.

There needs to be clarification between whistle-blowing and whinging
and their respective negligence and novel thought. Clinicians bold enough
to break the mould (or indeed 'rules' ) should be nurtured and carefully
encouraged - not outed as creatures of 'alarm, distress and anger'.

I read the news '"Disruptive" doctors are often found to be
perfectionists' with a feeling like Cassandra viewing the Trojan Horse. It
has been increasingly clear for years [1] that selecting the most
'conscientious' applicants for medical education, and then rewarding their
most relentless pursuit of narrowly focused achievements will promote a
cadre of senior doctors with obsessive approaches to medical practice. At
the moment, senior practitioners are mainly male, and complaints have been
mainly about men. However, in the general population of schoolchildren,
pathological perfectionism is at least as common in girls as boys and high
A-level grades are more common in young women. Watch this space.....